Describe and evaluate one treatment or therapy from each of the following approaches

1. Describe and evaluate one treatment or therapy from each of the following approaches By Clarissa Cheung

2. Social Approach – Family Therapy Due to the frequently close relationship between eating disorders and family life, therapy sessions often involve whole family. During family therapy sessions, a therapist will, for example, show the family members specifically how to deal with the disruptions caused by the eating disorders and teach them more about the disorder so they can understand it better. In a family-based therapy for anorexia: • Parents take charge of refeeding the patient • Sibling are there as support for the patient • No blame is put on the ill teen • The disorder and patient are separated (externalizing the illness) There are three phases to the treatment: • Weight restoration • Return to independent eating • Healthy adolescent development

3. Social Approach – Family Therapy • Lock & Grange (2001) showed positive progression by comparing the ideal body weight (IBW) of different family-based treatment studies of adolescent with anorexia nervosa, where only 1 out of 6 patients with longer duration of illness (more than 11 months) appeared to not to respond well to the treatment. Strengths: • Prevents long-term hospitalisation and affecting the adolescents social life. Adolescents are not held responsible for the illness, which takes away the issues of blame and labelling the person and places the emphasis on the disorder. • Lock & Grange (2001) have successfully constructed a manual that family and therapists are able to use to treat patients with anorexia. Weaknesses: • It only seems to work for adolescents that have been ill for a shorter period of time (less than 3 years). Russell et al reported that the duration of illness had a negative effect on the treatment. • Patient and family are required to play a active role during the phase of treatment and this maybe difficult when the patient itself have a lack of motivation to recover or are egosyntonic – where the patient does not see anything wrong with themselves. Ethical Issues: • It maybe seen as unethical to force the adolescent into the therapy when they believe that there is nothing wrong with themselves. Social Control: • High social control as the development of anorexia is mainly due to how the adolescent think how society view themselves.

4. Cognitive Approach – Cognitive Behavioural Therapy (CBT) The cognitive element of CBT assumes that our beliefs about the world affect how we see the world and ourselves, and the behavioural element aims to change our behaviour. The CBT model was first put forward by Beck (1976). CBT focuses on present behaviour and thoughts instead of focusing on how those thoughts developed. Therapist accepts the patient’s perception of reality and then uses this misperception to help the patient manage. It aims to allow patient to use information from the world to make adaptive rather than maladaptive decisions. The CBT model hypothesises that situations in themselves do not cause psychological distress, rather it’s the way that people interpret, make sense of an react to situations. People will experience distress if they interpret a situation negatively or react in a negative way; e.g. When someone looks at you, you make think that something’s wrong with you and experience distress. Interventions based on the CBT model therefore aim to correct these biases in thinking processes and behavioural reactions. Core beliefs and assumptions are developed through our experiences as we grow up. If a person had a difficult or traumatic life experiences in their childhood they are more likely to develop negative core beliefs and assumptions, which result in everyday negative automatic thoughts (NATs). A CBT sessions tends to last about 50 minutes. In each sessions an agenda is set so that both the therapist and patient know what they aim to get out of the sessions. The therapist helps the patient to identify their faulty interpretations of the world and correct them. This is done by questioning and challenging maladaptive thoughts so that the patients realises they are incorrect and can change them to more realistic thoughts.

5. Cognitive Approach – Cognitive Behavioural Therapy (CBT) • Chadwick (2000) studied 22 schizophrenics who heard voices. They each had 8 hours of CBT, and they all had reduced negative beliefs about how powerful the voices were, and how they voices controlled them, thus allowing them to live with the voices better. • Gould et al. (2001) carried out meta-analysis of studies that looked at effectiveness of CBT in conjunction with taking antipsychotics. He found that there was a large reduction in positive symptoms inmost cases, drop-out rates of about 12%, considerably lower than those who stop taking antipsychotics without CBT. • Pfammatter (2006) carried out a meta-analysis on CBT and found that it was highly effective in reducing severe positive symptoms. Strengths: • Therapy is evidence-based. Kuyken et al. (2008) suggested a form of CBT was more effective in preventing relapse and in improving quality of life than using antidepressants. • It’s backed up by government funding in the UK, maybe because it’s fairly quick to show results and is relatively cheap to provide. Weaknesses: • Many data about the effectiveness of CBT come from self-report, and such data are said to be unreliable. E.g. Demand characteristic may occur, where the client may want to please the therapist and say the therapy is working, giving a socially desirable answer. • Stiles et al. (2006) found that, in general, all psychotherapies have the same success rate in spite of their different theories and techniques. Ethical Issues: • Early experiments are unable to replicated, as it’s considered unethical to make a control group where the patients are not given therapy when it’s been proven to be effective.

6. Psychodynamic Approach – Free Association The aim of this therapy is to enable anorexic to cope better with internal conflicts that are causing disturbances. By uncovering these unconscious conflicts, the anorexic can work through them at a more conscious level. The therapist uncovers, explains and helps the patient come to terms with their conflicts. The patient lies on in a couch position where they can’t see the therapist – to avoid any demand characteristic and allow open honest feelings to flow through. • Freud often asked his patients to talk freely during therapy about their early memories and how they felt about people in their lives. If they seemed to run out of things to say, Freud would give them key words; e.g. ‘happiness’, ‘love’ or ‘fear’. When Freud asked them direct questions their replies were often fairly predictable, but when they are talking freely they occasionally said things that were more revealing. Freud thought they seemed to give clues about what was going on in their unconscious mind. Strengths: • It’s in depth and includes all aspects of functioning from early childhood onwards, so takes all experiences into account. • Analysis of what the patient says may provide a useful tool in psychotherapy. It appears to provide access to the unconscious , allowing subsequent interpretation. Weaknesses: • It may be inappropriate for people with certain disorders. Encouraging the client to talk at length about the issues on their mind, may reinforce thoughts that are already obsessive. • Interpretation of what the client says is clearly subjective and may be considered unscientific. Therefore, it’s not possible to validate the interpretation of free association.

7. Biological Approach – Use of drugs - Chemotherapy Drug treatments are known as chemotherapy - using chemicals to change the way the brain or body works. Drugs that change the way a person thinks or behaves are called psychoactive drugs. Drugs used to treat mental disorders - psychotherapeutic drugs - alter the chemical functioning of the brain by affecting the action of neurotransmitters. • Pickar et al. (1992) compared the effectiveness of clozapine with other neuroleptics and placebo drug. He found tat clozapine was the most effective in treating schizophrenic symptoms, even in patients that did not respond to previous drugs, and the placebo was the least effective

8. Biological Approach – Use of drugs - Chemotherapy Strengths: • Drugs allow the patient to live in society, so avoiding being institutionalised by a long-term stay in the hospital. It also allows them to access other therapies, which may cure them. • Emsley (2008) studied the effect of injecting the antipsychotic drug rispridone. He found that those who had the injection early on in their disorder (schizophrenia) had high remission rates and low relapse rates. 84% of the patients had at least 50% reduction in positive and negative symptoms, and over 2 years of the study, 64% of the patients went into remission. Weaknesses: • All of the drugs have side-effects; e.g. Sedation, dry mouth, constipation and weight gain etc. • Drug treatment cannot be seen as a cure, as patients have to be kept on constant doses of the drug to maintain the therapeutic effect. Ethical Issues: • It may be seen as unethical to force the patients to take these drugs even if it’s for the patients’ own good as the painful side effects may negatively reinforce the patients to avoid taking the drugs.

9. Learning Approach – Token Economy Token economy programmes (TEPs) are based on operant conditioning, the idea is that behaviour is repeated if rewarded and stopped if not rewarded. TEPs are a form of behaviour modification because they aim to change behaviour to a required or desired behaviour. Positive reinforcement – is when a reward is given to someone for behaviour and behaviour is then repeated because of that reward; e.g. If someone with schizophrenia does not show appropriate social skills then when appropriate, like they talk to someone, then they can be rewarded and this would then encourage this behaviour. If the complete required behaviour is not exhibited immediately, shaping can be used where rewarding behaviour moves closer to the required behaviour. E.g. If someone with schizophrenia is required to carry out a fairly complex task, like stop talking to themselves, they could be rewarded step-by-step. Negative Reinforcement – is when a person wants to remove something unpleasant so they behave in such a way to remove the negative issue; e.g. if an anorexic feels anxious when they eat they would then stop eating to avoid the anxiousness that is caused by eating, and the anorexic behaviour of not eating is then negatively reinforced. Punishment is rarely used, it models aggressive or negative behaviour and does not help to develop required behaviour, though it might put a stop to undesired behaviour. E.g. Someone with schizophrenia living in a psychiatric hospital may not be allowed to go to crowded areas if they wanted to go as psychiatrists may not agree if it causes danger and panic to the public. Tokens are given as rewards to desired behaviour and these tokens are then exchanged later on for something desired. Undesired behaviour is ignored and not rewarded, although neither is it punished.

10. Learning Approach – Token Economy Eight steps of the programme: • Desired behaviour is decided; e.g. If we treat someone with anorexia then the desired behaviour would be for them to eat. • Decide the nature of the tokens; e.g. Use points or plastic counters or stickers etc. • Decide on the rewards available to be exchanged with the tokens. The individual must desire the rewards that will be bought. • Set achievable goals. The goals set must be realistic for the individual to achieve. • The programme is explained to the individuals concerned. They must be able to understand what is required of them and what the tokens mean. • Individuals are given feedback on their progress. E.g. the individuals need to know where they’re going wrong and why they’re not given tokens. • Decide how the tokens are exchanged. Arrangements has to be made for when the tokens can be exchanged; e.g. once a month. • The programme is reviewed. Goals should be reviewed, as well as how often tokens are given and how often the exchange takes place; e.g. If someone isn’t earning much tokens then their goals may need to be altered for them to achieve it easier or if not much people are exchanging their tokens then the rewards may not be desired as much so may need to be changed.

11. Learning Approach – Token Economy • Mumford et al. (1975) carried out a TEP with long-term schizophrenic patients. 14 institutionalised female schizophrenic patients, average length in stay of hospital was 30 years, who all had a severe case of schizophrenia were put on a programme where rewards were given for independent treatment. It was found that there were both qualitative and quantitative changes in the participants’ behaviours. Strengths: • TEPs seem to be effective at least for long-term schizophrenic patients; e.g. Mumford’s (1975) study. • The programme rests on a clear behavioural –management principles and is under-pinned by a well-researched theory. Research using animals has confirmed the reliability of the operant conditioning principles; e.g. Skinner’s box where animals were put inside a cage and would be rewarded with food when they pushed the lever, the desired behaviour of pushing the lever was reinforced by positive reinforcement. These types of studies have been repeated often enough to show that positive reinforcement is able to produce desired behaviours and so is reliable. Weaknesses: • A strong team is required for the programme as rewards must be consistent and clear, where everybody is rewarded for the same behaviour and given out at the appropriate time. This requires a high level management and commitment from staff and they may need thorough and costly training. • Learnt behaviour may not generalise to the outside world, as rewards in society are subtler and less frequent than tokens.

12. Learning Approach – Token Economy Ethical Issues: • It may be considered unethical if basic needs are classified within the desired rewards and needs to be exchanged for tokens ;e.g. If watching a desired TV programme is considered an reward then it might mean that we are abusing human rights if we’re not letting them watch TV. • It may also be considered unethical if we classify behaviours into desired and undesired based on our social norm and what we think is right. E.g. If someone likes to eat alone then it might be considered unethical if we classify ‘eating with someone else’ as their desired behaviour. Social Control: • There is limited social control in TEPs as it’s within an institutional setting; therefore, it’s hard to generalise the behaviours learnt to the society as they’re likely secluded from the society as they learn their behaviours.